Vaccines should ideally be given before starting treatment with Rituximab (RTX). If severity of the disease or other variables makes this impossible, vaccines should be given no sooner than six months after the start of the medicine and no less than four weeks before the next course is scheduled.
“Although there is no data, this approach may also apply for other B cell depleting or targeting treatment regimens,” Dr. Isenberg wrote in the article. “Vaccines can be administered during treatment with anti-tumor necrosis factor (anti-TNF) agents.”
The authors’ review of the literature leads them to suggest that the influenza and pneumococcal vaccine should be administered as they are in the general population. They also call for use of tetanus toxoid per normal guidelines. The one exception would be in those who have been treated with RTX within the previous 24 weeks. In this group, passive immunization with tetanus immunoglobulin would be indicated.
One of the most important aspects of the review is that it also points out what we don’t know. Identifying and addressing these areas can be as important as setting out what is known.
Current Controversies
There is currently some controversy about the use of live-attenuated vaccines (LAVs). Guidelines now in force suggest that LAVs should not be given to anyone being treated with biologics. Drs. Isenberg and Ferreira suggest that patients on immunomodulators should not receive measles, mumps and rubella vaccines or LAVs for influenza, varicella-zoster, yellow fever, and rotavirus vaccines. For most patients in North America, the main issue would be with protection from shingles via zoster. In most other cases, there are nonattenuated substitutes readily available.
It’s important to complete a thorough assessment of vaccination status before beginning the biologic regimen.
“The edict against live vaccines in this population has no real evidence to support it,” says Jeffrey R. Curtis, MD, William J. Koopman Endowed Professor in Rheumatology and Immunology at the University of Alabama at Birmingham. “The current prohibition is largely the result of the Centers for Disease Control and Prevention [CDC] being appropriately conservative because it could be dangerous.”
Since the CDC statement, there have been multiple studies and a growing evidence base suggesting that this may not be as much of a concern as originally thought. Dr. Curtis points to a trial of HIV patients who were given the zoster vaccine in which no safety concerns were raised. He is involved with a new study funded by the ACR and National Institutes of Health that just began enrolling patients and may help better define these issues in those with rheumatic diseases.